title: Mitral procedure selection in patients on dialysis: does mitral repair influence outcomes?
abstract: OBJECTIVE
  To examine the likelihood of mitral valve repair among dialysis patients and the influence of mitral procedure selection on surgical outcomes in this cohort.
  
  
  METHODS
  Among patients undergoing isolated primary mitral valve surgery in the Society of Thoracic Surgeons Adult Cardiac Surgery Database (2002-2010), we used logistic regression models to evaluate the following: (1) the likelihood of attempted and successful mitral repair among dialysis patients (2008-2010), and (2) the impact of mitral procedural selection on surgical mortality and composite mortality/major morbidity experienced by dialysis patients (2002-2010). Patients with endocarditis and those undergoing emergent or major concomitant surgeries were excluded.
  
  
  RESULTS
  The study cohort consisted of 86,563 patients, of whom 1480 (1.7%) required preoperative dialysis. Dialysis patients had a high comorbid burden, including a high prevalence of congestive heart failure, stroke, diabetes, peripheral vascular disease, chronic obstructive pulmonary disease, and prior myocardial infarction. Dialysis-dependent patients had a lower propensity for mitral repair (44.6% vs 61.5%; P = .0010; adjusted odds ratio [OR], 0.69; 95% confidence interval [CI], 0.61-0.78); although the odds of successful repair (when attempted) were similar for dialysis versus nondialysis patients (OR, 0.87; 95% CI, 0.65-1.17). Compared with nondialysis patients, dialysis patients experienced a higher mortality rate (9.3% vs 2.3%; P < .0001; adjusted OR, 3.91; 95% CI, 3.17-4.81) and composite mortality or major morbidity (40.9% vs 15.9%; P < .0001; adjusted OR, 2.72; 95% CI, 2.41-3.07); however, adjustment for procedure selection did not substantially attenuate this effect (2.3% and 2.1% change-in-estimate for mortality and composite mortality/major morbidity, respectively).
  
  
  CONCLUSIONS
  Dialysis patients undergo mitral repair less frequently, although repair success is equally likely when attempted among dialysis versus nondialysis patients. Dialysis-dependent renal failure is associated strongly with early mortality and major morbidity. However, procedure selection (repair vs replacement) does not appear to have a clinically meaningful impact on these short-term outcomes.
authors.affiliation: Department of Surgery, Southern Illinois University School of Medicine, Springfield, Ill. Electronic address: cvassileva@siumed.edu.
authors.forename: Christina M
authors.initials: CM
authors.lastname: Vassileva
authors.affiliation: Division of Cardiology, Duke University Medical Center, Durham, NC.
authors.forename: J Matthew
authors.initials: JM
authors.lastname: Brennan
authors.affiliation: Department of Cardiac Surgery, University of Maryland Medical Center, Baltimore, Md.
authors.forename: James S
authors.initials: JS
authors.lastname: Gammie
authors.affiliation: Duke Clinical Research Institute, Durham, NC.
authors.forename: Shubin
authors.initials: S
authors.lastname: Sheng
authors.affiliation: Department of Surgery, Southern Illinois University School of Medicine, Springfield, Ill.
authors.forename: Theresa
authors.initials: T
authors.lastname: Boley
authors.affiliation: Department of Biostatistics and Bioinformatics, Duke University, Durham, NC.
authors.forename: Paramita
authors.initials: P
authors.lastname: Saha-Chaudhuri
authors.affiliation: Department of Surgery, Southern Illinois University School of Medicine, Springfield, Ill.
authors.forename: Stephen
authors.initials: S
authors.lastname: Hazelrigg
mesh_terms: D000368:Aged; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D015897:Comorbidity; D005260:Female; D006349:Heart Valve Diseases / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery*; D016017:Odds Ratio; D018579:Patient Selection; D006435:Renal Dialysis / Q000009:adverse effects / Q000401:mortality; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome